What medications should be held preoperatively in a patient with hypertension, diabetes, and impaired coagulation?

Preoperative Medication Management

Medications to HOLD Before Surgery

For patients with hypertension, diabetes, and impaired coagulation, the following medications must be discontinued preoperatively at specific intervals to prevent bleeding complications and metabolic derangements.

Antiplatelet Agents (Impaired Coagulation)

• Clopidogrel and ticagrelor must be stopped at least 5 days before elective surgery to limit blood transfusions and reduce major bleeding complications 1, 2
• For urgent surgery, clopidogrel and ticagrelor should be discontinued for at least 24 hours to reduce major bleeding complications 1
• Prasugrel requires at least 7 days of discontinuation before elective surgery 1
• Aspirin should be stopped 7-10 days preoperatively only in patients at low cardiovascular risk undergoing high bleeding-risk procedures (intracranial surgery, spinal canal surgery, posterior chamber eye surgery) 1, 3
• Glycoprotein IIb/IIIa inhibitors (eptifibatide, tirofiban) should be stopped 2-4 hours before surgery, while abciximab requires at least 12 hours 1

Diabetes Medications

• Metformin must be stopped the night before surgery in patients with risk factors including renal failure (creatinine clearance <60 mL/min), dehydration, fasting, concurrent ACE inhibitors/ARBs/diuretics/NSAIDs, or severe heart failure (LVEF <30%) 1
• Metformin should not be restarted until 48 hours after major surgery and only after confirming adequate renal function 1
• Sulfonylureas and glinides should be held on the day of surgery to prevent hypoglycemia during fasting 1
• DPP-4 inhibitors (sitagliptin) do NOT require discontinuation and can be continued perioperatively 4

Antihypertensive Medications

• ACE inhibitors and ARBs may be discontinued on the day of surgery due to increased risk of intraoperative hypotension and acute kidney injury, though this recommendation is based on lower-level evidence 5, 6
• Diuretics should be discontinued on the day of surgery and resumed postoperatively 6

Dietary Supplements (Bleeding Risk)

• Hold for 2 weeks before surgery: aloe, arnica, boldo, bromelain, cat's claw, danshen, devil's claw, dong quai, feverfew, garlic, ginger, ginkgo, ginseng (all types), horse chestnut, saw palmetto, turmeric, and vitamin E 1
• Chondroitin and glucosamine may be held for 48 hours due to shorter half-lives 1

NSAIDs (Bleeding Risk)

• NSAIDs should be withheld for five elimination half-lives before surgery 1
• Specific timing: ibuprofen 2 days, naproxen 2-3 days, meloxicam 4 days, piroxicam 10 days 1, 7

Medications to CONTINUE Through Surgery

The following medications carry greater risk if discontinued than if continued, even in patients with impaired coagulation:

Critical Continuations

• Beta blockers must be continued without interruption in patients already taking them chronically, as abrupt discontinuation causes rebound hypertension and coronary ischemia 1, 5
• Clonidine must be continued perioperatively to avoid rebound blood pressure elevations that can precipitate coronary ischemia 5
• Aspirin (100-325 mg daily) should be continued in patients with established cardiovascular disease, recent MI, or recent cardiac stent placement, as the thrombotic risk of discontinuation exceeds bleeding risk in most surgical procedures 1, 3, 8
• Statins should be continued without interruption and never discontinued before or after surgery 1
• Calcium channel blockers should be continued on the day of surgery 6, 9

Special Considerations for Impaired Coagulation

The decision to hold antiplatelet therapy depends on balancing thrombotic versus bleeding risk:

• In patients with drug-eluting stents, elective surgery should be postponed 6-12 months after stent placement, and dual antiplatelet therapy must be continued 8
• For bare-metal stents, delay surgery for 30 days after placement 8
• Most surgical procedures can be performed safely on low-dose aspirin alone, except those with bleeding in closed spaces 3
• The thrombotic risk of stopping antiplatelet drugs exceeds the bleeding risk in most cases 3

Critical Pitfalls to Avoid

• Never abruptly stop beta blockers or clonidine preoperatively, as this causes dangerous rebound hypertension and ischemia 5
• Do not substitute heparin or LMWH for antiplatelet therapy, as this does not protect against coronary or stent thrombosis 3
• Defer elective surgery if systolic BP ≥180 mmHg or diastolic BP ≥110 mmHg 5
• Do not restart metformin too quickly postoperatively without confirming adequate renal function, as lactic acidosis carries 30-50% mortality 1
• Maintain SBP >90 mmHg or MAP ≥60-65 mmHg perioperatively; avoid excessive blood pressure lowering 5